Healthcare Provider Details

I. General information

NPI: 1437600657
Provider Name (Legal Business Name): PUTNAM COUNTY MEDICAL HOME CLINICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S 18TH ST
UNIONVILLE MO
63565-1642
US

IV. Provider business mailing address

2221 GREEN ST
UNIONVILLE MO
63565-1426
US

V. Phone/Fax

Practice location:
  • Phone: 660-947-2300
  • Fax: 660-947-2307
Mailing address:
  • Phone: 610-737-4704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DAWN FAIRLEY
Title or Position: SOLE OWNER
Credential:
Phone: 610-737-4704